Fax Registration for SEAK Hyannis 2003

Fax Registration for SEAK Hyannis 2003

SEAK, Inc. Hyannis July 2003
REGISTRATION FORM

To register, call SEAK, Inc. at 508-457-1111, or Print this form and complete the requested information (neatly, please),
and FAX to SEAK, Inc. at 508-540-8304, with credit card information.
Or mail with credit card information or check to: SEAK, Inc. PO Box 729, Falmouth, MA 02541

priority code: net

Please register me for:
___Twenty-third Annual Workers' Compensation and Occupational Medicine
       Seminar ($695: July 22-24, 2003)

___Designing Effective Return To Work Programs ($295:July 21, 2003)
___AMA Guides to the Evaluation of Permanent Impairment ($295:July 21,
     2003)
___ADA, FMLA, and Workers' Compensation: In Depth ($295:July 21, 2003)
___Psychological Disorders in the Workplace: Prescriptive Accommodations
     ($295:July 21, 2003)
___Violence in the Workplace: A Continuing Threat ($295: July 21, 2003)
___Negotiating Skills For Occupational Health Professionals ($295: July 21,
     2003)

I would like to apply for the following credits (Please check as many as are applicable):

__Attorney __Case Manager __Disability Specialist __MD/DO __ Occupational Health Nurse __ Rehabilitation Counselor __Nurses

Check Enclosed (made out to SEAK, Inc.)

Credit Card Billing Type of card: ___Visa ___MC ___AE

Card No.

Exp. Date:

Signature

Please print or type all information. Use abbreviations as necessary.

Name                                                                                                                                                              Title

Name of Organization

Address

City                                                                           State                        Zip

Phone (Area Code/Number)                                       Fax

E-Mail

Specialty

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SEAK, Inc. FAX (508) 540-8304